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I Need A Witness
Wednesday, January 24, 2007, 5:45 AM
A witness to this situation. In the sense that marriage has been described as a witness to your life, that’s how I need a witness.
In particular, I am awake at 4 this morning because neither my stomach nor my heart, will let me slumber. (I didn’t tell you all that I have gastritis, GERD and potentially an ulcer, and if this round of meds doesn’t stop my symptoms, I get to have a tube down my throat into my gut to take a peak…)
I have a patient I need to tell you about. I can’t give you much in the way of detail. I am sorry. He’s a year younger than me. Smart and kinda geeky….so I felt a bond with him from the first. I see him weekly to maintain a high risk/high tech procedure that typically is not taught to patients or caregivers. That’s unusual in this day and age when so much of my job as a home health nurse is to teach the patient and/or the caregiver how to do all manner of formerly nurse only procedures. His insurance, like most, follow Medicare regulations for eligibility of services. The biggest requirement to be eligible for homecare is that you be homebound. But you see, homebound means different things to different people.
To some it means they are stuck at home without a car. To some it means they just don’t feel like leaving home very often and only do so for rare and infrequent purposes or are psychological unable to leave home. To others it is a “severe and taxing effort” requiring the assistance of at least one person for safety. Driving is an automatic disqualifier. If you drive…you are not homebound. Being “homebound” is a subjective assessment according to Medicare. Guess who gets to determine “homebound” status? Yes, I do. I have been doing it for coming up on ten years. I have been exhaustively trained in administering this rule. Being homebound is a functional ability. You may be functionally able to leave home and choose not to. That doesn’t make you homebound, unless of course, you are diagnosed with a psychological illness. We want our patients to graduate to the non homebound status. It means they have gotten better. So while I am assessing all the things a nurse assesses when I make a home visit, I am acutely aware of what their functional status is and prepare the patient accordingly. I set them up for outpatient therapy or intervention if it is required. This is a good thing. That is my goal with every patient.
My patient, this patient I am telling you about, is a young man with a particularly fatal type of cancer. He has progressed, this last two weeks, to the point where he had started to go to work again. Amazing to me, because he has already outlived his prognosis. And without sounding like a cliché, it’s because of his attitude. He is very involved in his care and…you are gonna love this, keeps an excel spreadsheet of his intake and output. Yup, just my kinda geek. Granted, after going to work for three or four hours, he returns home to sleep for the same amount of time. It is a “severe and taxing effort” for him, bless his heart. Yet so good for his soul. And he continues to do it. Going once, I would overlook it. Going twice, I begin to question his other out-of-home excursions and discuss his functional ability. Last Monday I tell him I need to verify that his insurance does follow Medicare rules on homebound status because, he is driving to work. We discuss how well he’s doing. He says he will call his insurance company to see if he is eligible for any special programs, insurance wise, because of his age and disability that would override the requirement for being “homebound” and call me if he finds out anything.
Now, let me explain something to you. If I continue to see this patient and his insurance company finds out he is not homebound (which would mean I would have to falsify his records every time I visit), they will not only refuse to pay for any further visits for homecare….they will deny his entire episode. Regardless of how homebound he was in the beginning. That is the way of insurance. Guess who bears the responsibility if this happens? Guess who gets “sanctioned” then? I will bear the brunt of responsibility for either knowing he wasn’t homebound and continuing to see him or not assessing appropriately enough. I get written up. I get in trouble.
The next day, Tuesday, I discuss at length the patient’s condition with the insurance liaison in our office. She is adamant. This insurance company follows Medicare homebound status to the letter. No matter how “severe and taxing” the effort is, he has gone more than once, he is driving…he is no longer homebound. I regretfully call the patient to inform him of this and he says he has not called his insurance company yet and I urge him to do so. I tell him I will call his doc to get the ball rolling on outpatient services. He says he will let me know if he finds out anything. On Friday afternoon, after not hearing from my patient, I call his doc and speak with his doc’s assistant to inform her that he is no longer eligible for homecare because he has started driving to work. She tells me she will get working on it when I remind her that he will need bloodwork and a procedure on Monday and that his pharmacy will be looking for those results.
Well, guess what? I hurt my back this weekend and was out sick on Monday. Tuesday, I find out he called on Monday evening, to the on call nurse, to find out why I hadn’t come. Upon hearing this, I immediately call his doc’s office and of course, the nurse responsible for arranging the outpatient services knows nothing. Great. I call the pharmacy to let them know the situation so they won’t be looking for the lab results. I call the patient and while we did not have a heated or angry conversation, it got “pointed” a few times. He then informs me that he spent many hours in the ED on Saturday because of a bladder infection. I asked him why he didn’t call us or at least let me know of the change of his condition…that could have changed his homebound status but only a home visit with an assessment could determine that. He doesn’t really answer me. He says… “Oh”. He cites me chapter and verse out his insurance handbook on homebound status. He interprets the meanings differently then would a homecare agency or staff. I try to educate him, but he continues to not accept what I am telling him. I tell him I will have my Branch manager call him but that I feel confident in my ability to determine homebound status.
My heart hurts and my stomach isn’t happy either. I feel bad about how this has evolved. If his doc’s staff had done their job…he would’ve had a smooth transition or at least they could have notified me of his change in condition (which the patient failed to do) and I could have gone out to see him and assess him. I want to provide good, compassionate care for my patient within the confines of insurance regulations. I don’t do my company any favors by seeing a patient who’s not homebound. We are talking thousands of dollars of care that he has received, that we potentially might not get paid for if I don’t follow the rules. And trust me…I would bear the brunt of this if that happened. Possibly, the company would have “fined” me the cost of my portion of his care.
So, now this patient is very angry with me. He has written an articulate but scathing letter to our agency. I have lost my therapeutic relationship with him. I am tempted to blame myself…by saying that I gave him a situation to have to “deal” with at a time in his life where he doesn’t need any “situations”. But I must let him be responsible for his actions as well.
My heart hurts and my stomach isn’t happy either. ♥Pam
I'm Pam and Bill.
We are DINKS with DOGS & CATS and chickens and turkeys.
Met on a blind date in October of 1993 and married in August of 1994. We have five dogs and two cats.
We live on about 122 or so acres in Southern Vermont. About 12 acres of pasture and the rest is woodland..